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Birthing Baby
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Contact Information
Mother's Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Best Phone Number
*
Email
*
Your confirmation will be sent to the email address you provide above.
*** Please double check that it is correct. ***
Confirmation is usually sent within a few hours, but occasionally it can take up to 48 hrs. Please add sherry@birthingbaby.com to your address book to avoid delay in receiving your confirmation.
Partner's Name
*
First
Last
Relationship of Partner to Mother
*
Husband
Life Partner
Other (Mother, Sister, Boyfriend, Friend, etc.)
If other, please specify:
*
How did you find out about Birthing Baby?
*
Midwife / Doctor
Doula
Friend
Internet Search
Other
Name of referral source or search engine used:
*
Pregnancy Information
Estimated due date (mm/dd/yyyy)
*
This will be the mother's
*
Select One
First birth
Second birth
Third birth
Fourth birth
Fifth birth
Sixth birth
Other
We plan to
*
Select One
Have an unmedicated labor & birth
Use medications only as a last resort
Use medications
Have a scheduled cesarean
Undecided
Is there anything you wish to let me know about a previous pregnancy and/or birth experience?
*
Name of hospital, birth center, or homebirth service
*
Name of midwife or doctor planning to attend
*
The birth attendant is a
*
Select One
Certified Professional Midwife and/or Licensed Midwife
Certified Nurse-Midwife
Doctor of Osteopathy
Family Physician
Obstetrician
Other
Have you had any complications with this pregnancy?
*
Choose Your Class Dates
All classes are scheduled for Wednesday evenings from 7:00 PM until 9:15 PM.
*
Select One
January 29 - March 26, 2014
April 2 - May 28, 2014
June 4 - July 23, 2014
Calculate Amount Due
Do you qualify for the Early Registration Savings?
*
Yes! We are paying in full before the Early Registration Deadline. We owe $285, which incudes a $50 non-refundable deposit.
No. We will not be paid in full before the Early Registration Deadline. We owe $300, which includes a $50 non-refundable deposit.
Need to look up the
Early Registration Deadline
for your class series?
It is typically around 2 weeks before the date of the first class.
Payment Options
Today, we will
*
Pay the full amount we owe online.
Mail a check for the full amount we owe.
Pay the $50 non-refundable deposit online to reserve our spot in the class.
Mail a $50 check for the non-refundable deposit to reserve our spot in the class.
Payment Methods
Personal Check and Cash Payments
- If you prefer to mail in some or all of your amount owed, complete your registration by clicking the "Register" button once. A screen will appear which will confirm your registration was sent. I will contact you by email within 48 hours to confirm your registration and payment method.
Credit or Debit card Payments
- You can use PayPal to pay online with a credit card or debit card. You do not have to create a PayPal account to do so and it does not cost you anything to use this service. (I pay a 3% fee to receive the funds).
To complete your registration and pay online, click the "Register" button once. You will then be able to pay online.
Register
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